Wesper identifies worsening sleep apnea with oral appliance titration. 

Abstract

A 71-year-old woman with a BMI of 26.9 was previously diagnosed with mild sleep apnea and snoring via PSG and was fitted with a mandibular advancement device.

After two titrations, the patient reached out to the Wesper sleep expert with concerns about worsening her sleep apnea while using her oral appliance.

Overall, there was a clear decline in both breathing quality and subjective sleep quality after the initial titration.

The Sleep Expert informed the patient that an oral appliance could occasionally worsen sleep apnea during early titration, and we would typically expect to see an improvement with additional adjustments.

The patient agreed to continue using their oral appliance and work with their dentist. 

A significant problem with most OSA therapies is a need for more patient education on what to expect during and after the therapy adjustment period.

Many patients are unaware that they may not see an immediate improvement or even have worsening symptoms during the initial use of their appliance. 

Background 

A 71-year-old woman with a BMI of 26.9 was previously diagnosed with mild sleep apnea and snoring via PSG and was fitted with a mandibular advancement device. Her dentist recommended using Wesper to help aid in the titration of her oral appliance.

After two titrations, the patient reached out to the Wesper sleep expert with concerns about worsening her sleep apnea while using her oral appliance. She stated, “I am getting very stressed out, and I’m afraid to sleep at night.” Her chief complaints were that she was frequently waking up feeling like she couldn’t breathe, worsening sleep quality, and high anxiety. The Wesper sleep expert recommended she book a consultation to review her results. 

Findings 

The patient completed found Wesper tests while wearing her oral appliance. The first test was conducted before the first titration of her appliance. The remaining three tests were conducted after the first titration of her appliance.

Before the first titration of her oral appliance, the patient’s data demonstrated a breathing event score of 9 events per hour. They snored for 10% of her tests, which was consistent with her diagnosis of mild OSA. On the post-test sleep quality questionnaire, the patient rated her sleep quality a 3, which is “fair” on a very poor to excellent scale.

The three tests taken after the first titration of her oral appliance showed a steady increase in breathing events per hour. Her final and worst test demonstrated a breathing event score of 24 per hour, and the combined average breathing event score was 17.6 across the three tests. This is an average increase of 8 breathing events per hour compared to her pre-titration results. Interestingly, the three post-titration tests did not report snoring, demonstrating that the titration effectively reduced snore time. The post-rest subjective sleep quality score was an average of 1.6, which sits between “very poor” and “poor” on the rating scale, a decline from “fair” on her pre-titration test.

Overall, there was a clear decline in both breathing quality and subjective sleep quality after the initial titration. While the breathing event score is not the same as AHI, the severity level of a breathing score is correlated with the severity of AHI. If someone has a breathing event score of 5-14, we expect to see the patient's AHI fall into this range. Therefore, we can predict that this patient’s sleep apnea worsened after the first titration of her oral appliance. 

Meeting With the Wesper Sleep Expert 

During the meeting with the Wesper Expert, the patient expressed serious concern about her oral appliance being an appropriate treatment for her OSA and questioned whether she should discontinue its use.

The Wesper sleep expert explained to the patient that mandibular advancement devices must complete the titration process before concluding if an oral appliance will correct their sleep apnea. The expert also informed the patient that an oral appliance can occasionally worsen sleep apnea during early titration, and we would normally expect to see an improvement with additional adjustments.

The patient was advised to reach out to their dentist as soon as possible to discuss their results and set up an appointment for further titration. The patient agreed to continue using their oral appliance and work with their dentist. 

Conclusion 

The success rate for OSA treatment using custom-made adjustable Mandibular Advancement Devices is approximately 60-80% and is most successful in individuals with mild OSA [1]. Studies have shown that appliances set to 70% of maximum protrusion offer the most benefit. However, it may take several adjustments during the titration process to arrive at this setting [2].

A significant problem with most OSA therapies is a lack of patient education on what to expect during and after the therapy adjustment period. Many patients are unaware that they may not see an immediate improvement or even have worsening symptoms during the initial use of their appliance.

Studies have shown that patient education and providing patients with an easily accessible sleep support team can improve OSA therapy and satisfaction. 

Explanation of metrics: 

• Breathing events—Increased respiratory effort, including reduced airflow and prolonged breathing stoppages. 
• Snoring Percentage - The percentage of time the patient was snoring during the test.  
• Perceived Sleep Quality Score - Post-test questionnaire asks patients to rate their subjective sleep quality during their test on a scale of 1-5 (1 = very poor, 5 = excellent). 

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4626015/
2. https://pubmed.ncbi.nlm.nih.gov/27999120/